ESPEN Congress Leipzig 2013

LLL Session - Nutrition in paediatric patients

Enteral nutrition in paediatric patients

S. Kolacek (HR)

Sanja Kolaček

CHILDREN’S HOSPITAL ZAGREB, Croatia

Enteral Nutrition (EN)

in Paediatric Patients

EN in PAEDIATRICS

Lecture objectives

Selection of formula

Complications

EN: Indications & contraindications

How to choose site & route & mode

Nutritional support in children

Nutritional Support

in Sick Children

To treat a disease

(food allergy in infants, Crohn’s disease......)

GOALS

optimal growth

neuromotor development

minimize gastrointestinal symptoms

promote normal feeding habits & skills

To provide energy & nutrients

to support:

Nutritional Interventions

in Sick Children

Depend on:

Age

Clinical picture

Possibility of oral intake

Absorptive & digestive capacity

Dietary habits

Costs

NUTRITIONAL INTERVENTIONS

Chosen approach should increase stepwise in respect to

underlying condition & impairment of nutritional status

Parenteral nutrition

Enteral feeding

Oral nutritional supplements

Nutritional counseling

Management strategy: nutritional

counselling & sip feeds

Get children eat more without unnecessary

restrictions

simplest, cheapest & safest nutritional support

if not enough than

Provide oral nutritional supplement - sip feeds

- whole protein based, pediatric formula, nicely flavored, with fibers

- energy enriched (1.3-1.5 kcal/ml) if more energy required, or if amount ingested is limited

Koletzko B, Goulet O. Nutrition support in children & adolescents; in : Sobotka L (ed). Basics in clinical nutrition, Prague 2011

Enteral Nutrition

Feeding directly into stomach

or duodenum / jejunum

over tube or stoma

DEFINITION

or / and

Oral provision of dietary foods

for special medical purposes

ESPEN Guidelines in EN, Clin Nutr 2006

ESPGHAN CoN Comment, JPGN 2010

EN vs. PN: Rule of Thumb

THEREFORE

improves GUT function & morphology

limits bacterial translocation & sepsis

decreases incidence of multiorgan failure

3x less expensive

ENTERAL INTAKE

Use GUT whenever possible

& as much as possible

Paediatric EN:

Evidence based guidelines

EN in Paediatrics

W H E N??

EN used as treatment of the disease (allergy, Crohn,

Total feeding time >4 h/day in disabled child

Not growing well on oral intake +

GIT function sufficiently preserved

B.

Not growing well ??? Growth failure >1 months in child <2 y

Growth failure >3 months in child >2 y

Change on centile charts >2 growth channels

Triceps skinfolds <5th percentile / age

A.

Axelrod D, et al. Pediatric enteral nutrition.JPEN 2006

ESPGHAN Commitee on Nutrition Comment, JPGN 2010;51

C.

EN: Clinical Indications

Enteropathies, pancreatic insufficiencies (CF...), short bowel syndrome

increased

Chronic diarrhoea of infancy, Crohn’s Primary disease management

Maldigestion & malabsorption

nutritional losses

Suck-swallow disfunction, acquired condition (facial trauma, coma...), anorexia, muscle weakness & fatigue

Inability to take enough food:

Burns, trauma, cystic fibrosis, congenital heart disease... Increased nutritional requirements

Inborn errors, impaired organ function (renal, liver, pulmonary) Altered metabolism

EN: Contraindications

Mechanical & paralytical ileus

Necrotizing enterocolitis

Intestinal perforation & obstruction

Major intra-abdominal sepsis

Selection of Formulae

for EN

Intestinal, liver & pancreatic function

>8 to 10 y adult formulae

Site & route & mode of delivery

osmolality, viscosity, costs, taste

small children

Age specific nutritional requirements

infants

Food intolerances or allergy

allergens, gluten, lactose, phenil-alanin...

Formula features:

POLYMERIC SEMI-

ELEMENTAL ELEMENTAL

Nitrogen (casein, lactalb., soy)

whole proteins small peptides amino-acids

Carbohydrates glucosae polymers

Fats LCT or LCT & MCT

Osmolarity 300 300 - 450 300 - 600

Indications multiple allergy,

malabsorption multiple allergies, severe malabs.

Advantages palatable, cheap hypoallergenic

rapid absorption non-allergenic

immunomodulatory

Disadvantages intact GIT bitter, expensive expensive, bad

taste, hyperosmolar

Selection of EN formulae

in respect to nitrogen source

MCT based • requires no lipase & bile • absorbed to portal blood (not lymph)

High energy

(1.3 - 2.0 kcal/ml)

• fluid restriction • increased energy requirements

High nitrogen (>15%) • catabolic patients • wound healing

High lipids (>35%) • respiratory problems, high energy requir.

Addition of

immunonutrients • glutamin, arginin, n-3 FA, nucleotides, TGF-beta & probiotics, prebiotics

Other disease specific • liver, renal, lung, diabetes

Selection of disease

specific EN formulae

Enteral Formulae Selection

role of disease-specific formulations

- Could be beneficial in certain

clinical conditions

- Good controlled studies in

children are lacking

CLAIMS SHOULD BE

EVALUATED CRITICALLY

Isocaloric (1 kcal/ml), iso-osmolar (300-350),

mostly gluten & lactosa free

Age adapted nutritional composition

Use adult formula only after 8-10 y

Polymeric formula

Selection of EN formulae

Standard paediatric formula

Addition of fibres??

Enteral Formula Selection:

addition of fibres

Elia M et al. Clinical effects of fibre containing

enteral formulae – systematic review & meta-

analysis. Aliment Pharmacol Ther 2008

• Significant benefit of fibre supplemented

versus unsupplemented EN formula in:

a. patients and healthy controls

b. predominant symptom diarrhoea & constipation

Enteral Formulae Selection:

take home message

Standard polymeric formula can be safely used

in >90% patients, irrespective of their basic

clinical condition, but with functioning GUT.

Fibres considered as a usefull addition

BEST

COST-BENEFIT RATIO

EN in CHILDREN:

Sites for delivery

in patients with high risk of aspiration

gastric outlet obstruction, pancreatitis..

less diarrhoea, better osmotic tolerance

STOMACH

physiologic

antimicrobial effect

reservoir - gradual release

tubes easily placed

JEJUNUM

ESPGHAN Committee on Nutrition. Practical approach to paediatric EN

JPGN 2010;51:110-122.

Gastric vs. Postpyloric

EN Application

Evidence - based

McGuire W, et al. Cochrane Database 2007 8 RTC in prematures

Increased GIT complications (RR 1.45) & increased mortality (RR

2.46) in postpylorically fed

Rosen R et al. JPGN 2011 GER episodes increased also in transpyloric feedings:

fasting 24.9 vs nonfeed period 3.3; p=0.001

Hospitalization for aspiration possible after transpyloric feeds initiated

Metheny NA et al. JPEN 2011 (critically ill adults)

Compared to stomach, % of aspiration decreased when tubes in

1st portion of duodenum by 11%, 13% in 3rd, 18% in 4rd portion

Pneumonia decreased only when tube beyond 2nd portion (p=0.02)

EN in CHILDREN:

Routes of delivery

TUBES (NG/NJ) if expected EN <6-12 wks

PVC Silicon or polyurethan

Stiff, release phalate

Traumatic

Cheap

Short duration (4-6 d)

Soft, flexible

Atraumatic

Expensive

Long duration (4-6 weeks)

Measuring tube

for infants and newborns

Measuring tube

for children

midpoint between

xiphisternum and

navel

oesophagus

stomach

xiphisternum

lung

trachea

duodenum

Cirgin Ellett ML et al. Predicting insertion length for gastric tube placement

in neonates. JOGNN 2011;40:412-421

Positioning of the NG tube

Positioning of NG Tubes

If necessary check by

abdominal x-ray

no aspiration of gastric content

pH >5

patient’s condition suggests aspiration

Suggested by

acid pH (≤5) of the aspirate

epigastric auscultation of injected air

correct external length of tube

ESPGHAN Committee on Nutrition. Practical approach to paediatric EN. JPGN 2010

Gilberson HR et al. Determination of practical pH cutoff level..............JPEN 2011;35

Method of placement

• endoscopically

• surgically

• radiologically

Endoscopy preferred • cheapest & quickest

• low rate of complications

Surgery preferred in • neurologically impaired

• combined with Nissen

EN in CHILDREN: route

PEG / PEJ

ESPEN Guidelines/PEG. Clin Nutr 2005;24

Raval MT, et al. J Pediatr Surg 2006; 41:1679-82

ESPGHAN CoN Comment. JPGN 2010;51:110-122

PEG & PEJ indicated if expected EN

duration longer than 6-12 wks

PEG / PEJ for EN in children

PRE-

PROCEDURE PROCEDURE POST-PROCEDURE

Discuss with

parents/child

In children general

anesthesia

Start feeding after 6 h

(even 3h safe**), resume

full feeds after 24 h

Laboratory tests (Hgb, platelets,

coagulation )

Pull method most

common Train parents

Antibiotic

prophylaxis usefull*

(cefazolin 30 min before

procedure)

Sufficient incision +

application of

povidone iodine

usefull for prevention

of infection

Early complications in

8-30%, most common

wound infection

Late complications up

to 40% (stoma related)

*Lipp A et al. Systemic antimicrobial prophylaxis for PEG. Cochrane Database 2006 (4)

• Jafri NS et al. Meta-analysis: antibiotic prophylaxis... Aliment Pharmacol Ther 2007.

** Corkins MR et al. Feeding after PEG in children... JPGN 2010

Management strategy: site & route

Expected Duration of Nutritional Support

More than 6-12 weeks

NO YES

Risk of Aspiration Risk of Aspiration

YES YES NO NO

NG tube Postpyloric tube Gastrostomy Jejunostomy

EN in CHILDREN:

Modes of delivery

BOLUS

FEEDING

CONTINUOUS COMBINED

Physiologic Utilization better Continuous over

night

Cyclical

hormon surge Less termogenic Bolus over day

Non-

restrictive

Look after:

a. gastric empying rate

b. gallbladder emptying!

Preserved oral

motor function

Koletzko B, Goulet O Basics in clinical nutrition. 3rd ed. Prague:Galen,2011

ESPGHAN CoN Comment. JPGN 2010;51;110-122

EN in CHILDREN:

Delivery sets

Expensive, sterile

inside Cheaper

Can hang un-opened

for 24 - 48 hours

Sterile formula* content to

be changed:

- every 8h in hospital

- every 12 h at home

- aseptic approach required

Closed system Open set, sterile feed

*In case of non-sterile powder formula, content

should changed every 4-6 hours

Bankhead R et al. ASPEN enteral nutrition practice recommendation. JPEN 2009

COMPLICATIONS

- look for -

PREVENTION & THERAPY

- take care on -

Gastrointestinal Diarrhoea, nausea, vomitting, bloating, abd. distension

Formula selection & delivery Osmolality, viscosity... Disease specific Stepwise introduction

Aspiration!! Monitoring gast. residuals

Technical Occlusion, migration, GIT lession

Tube, stoma selection & placement PVC vs. silicon Endoscopy vs. surgery

Infective* Gastroenteritis, septicaemia

Quality control & protocols Hanging time, hygiene...

Metabolic Fluid, glucose, electrolytes Trace elements, vitamins

Monitoring Growth (weight, height/length, skinfolds) Hematology, biochemistry

Psychological Oral aversion, altered taste

TEAM APPROACH!!!

*Roy S, et al. Bacterial contamination...J Hosp Infection 2005; 59

EN Initiation

Gradual increase in rate

and concentration

age

clinical condition (GUT !)

formula (osmolality !)

delivery route (jejunum !)

Depends on:

Kolaček S. Enteral nutrition support. In: Koletzko B, ed. Pediatric

Nutrition in Practice. Basel: Karger; 2013 (in press)

Weaning from

Enteral Nutrition

EN to be stopped when:

Stable condition + appropriate

nutritional status

May take days to many months

oral intake sufficient

growth appropriate

Enteral Nutrition in Children

Take Home Messages

4. Close monitoring & following protocols & supervised by dedicated Nutrition Care Team

1. Use GUT whenever possible & as much as possible

2. Standard polymeric formulas useful in >90% patients with best cost / benefit ratio

IF

3. EN is safe & effective method of nutr. therapy